Charles F. Mullen

Challenges and Opportunities in Optometry and Optometric Education

Dr. Charles F. Mullen Inducted into the National Optometry Hall of Fame

Logo for the National Optometry Hall of Fame

National Optometry Hall of Fame – Press Release (PDF)
National Optometry Hall of Fame – Full List of Inductees

Nomination Letter (excerpt)

Dr. Mullen became known as the “clinical architect” for establishing what would become known as one of the most impressive community-based clinical education systems in the country.

-Roger Wilson, O.D.

Nomination Letter (excerpt)

Dr. Mullen has achieved paradigm shifts for optometry by integrating the training of optometrists into a medical community model.

Dr. Mullen placed optometric students in clinical settings where there were integrated with other health care providers for their training. A complete appreciation of the magnitude of this paradigm shift which transferred optometry to the medical community model requires recognizing that the first legislation allowing optometry to use diagnostic agents was passed in 1971, and the appeal process lasted until 1974. The first legislation for therapeutic agents was passed in 1977. Thus, Dr. Mullen’s insight and implementation was even more remarkable in that it preceded the legal status of optometry having the tools to participate in the medical community model.

He should be credited with achieving the present position of optometry within the Department of Veterans Affairs (VA) in providing comprehensive patient care, training of optometric students and residents, and research.

His insight and implementation across the broad spectrum of professionals, researchers, members of the US Congress and relevant federal agencies was responsible not only for the readily observable achievements, but for many which are not quantifiable. An example was the prestige resulting from the status of optometry in the VA – extremely important in optometry’s legislative initiatives for expanding the scope of practice.

-Donald R. Korb, O.D.

Official Press Release (excerpt)

ST. LOUIS, June 30, 2009 – The National Optometry Hall of Fame honored two individuals for their contributions to optometry on June 26, 2009.

Dr. Charles Mullen has planned and redesigned optometry during his 33-year career. He built institutions of quality education, formed national healthcare policy and strengthened urban communities through optometric and ophthalmic care.

Dr. Mullen began work in the president’s office at the New England College of Optometry as special assistant for clinical development in 1970. He then served as executive director of the Eye Institute at the Pennsylvania College of Optometry from 1976 to 1990. Then, Dr. Mullen became director of the Optometry Service for the Department of Veteran Affairs in Washington, D.C. until 1996 when he became president of the Illinois College of Optometry. Dr. Mullen retired from the Illinois College of Optometry in 2002.

An instrumental figure in moving optometry to the forefront of primary eye care, Dr. Mullen understood that optometry and ophthalmology were complementary and worked to extend care to underserved populations.

by Charles F. Mullen

NEEI Compliance Protocol to Meet Medicare Guidelines for Optometric Training Programs

The New England Eye Institute (NEEI) is the Patient Care and Clinical Education Subsidiary of the New England College of Optometry. Click here for The NEEI Comprehensive Eye Exam Form (PDF)

To assure compliance with Medicare requirements for billing and reimbursement of comprehensive exams for new and established patients (CPT codes 92004 and 92014), NEEI adheres to the CPT definition of a comprehensive exam. CPT 2008 defines a comprehensive eye exam as follows:

Comprehensive ophthalmological services describes a general evaluation of the complete visual system. The comprehensive services constitute a single service entity but need not be performed at one session. The service includes history, general medical observation, external and ophthalmoscopic examinations, gross visual fields and basic sensorimotor examination. It often includes, as indicated: biomicroscopy, examination with cycloplegia or mydriasis and tonometry. It always includes initiation of diagnostic and treatment programs.

From this definition NEEI interprets the essential elements of a comprehensive eye exam (for which the attending doctor is personally responsible for performing except 1.b. and 1.c. below) to include the following minimum data set:

  1. Comprehensive eye and health history and history of present illness

    a. History of present illness, physical exam findings and medical decision making must be documented by attending doctor.

    b. Optometry students may document services in the medical record. However, the documentation of an E/M service by a student that may be referred to by the teaching physician is limited to documentation related to the review of systems and/or past family/social history.

    c. The teaching physician may not refer to a student’s documentation of physical exam findings or medical decision making in his or her personal note. If the student documents E/M services, the teaching physician must verify and redocument the history of present illness as well as perform and redocument the physical exam and medical decision making activities of the service.

  2. General medical observation
  3. External ophthalmic examination
  4. Ophthalmoscopic examination
  5. Gross assessment of visual fields
  6. Sensorimotor assessment
  7. Diagnosis
  8. Treatment

Optional features of a Medicare compliant examination include:

  1. Biomicroscopy
  2. Dilated ophthalmoscopic examination
  3. Tonometry

NEEI’s interpretation of Medicare rules for a comprehensive eye exam does allow for the involvement of optometry students in portions of the exam. However, to be Medicare compliant, the attending doctor is required to personally perform (or repeat) the essential parts of the examination listed above, except for the review of systems and/or past family/social history which may be documented by students.

Furthermore, the diagnosis and treatment plan must be supported by procedures actually performed by the attending doctor.(For example, a diagnosis such as glaucoma would require tonometry – in most cases – and thus tonometry would have to be performed (or repeated by the attending doctor.)

It must be clear from a record audit that the diagnosis and treatment were arrived at solely based on the attending doctor’s examination. The attending doctor must be able to advocate the position that the student’s findings were not considered in making decisions.

Additionally, NEEI’s compliance protocol states that the history of present illness, diagnosis, and treatment are essential exam components and thus the accompanying documentation of these essential elements are to be completed by the attending doctor, either by handwritten notes, through dictation and typed record, or via computer generated and typed method.

The NEEI Medicare compliance protocol does not require that the attending doctor repeat non-essential elements of the exam or elements that are not covered by Medicare, such as refraction.

The NEEI Comprehensive Eye Exam Form (PDF)

The NEEI comprehensive eye exam form has a column for the attending doctor to document essential elements. The form also has space for exam procedures such as biomicroscopy and other elements of an exam that would be repeated by the attending doctor as a matter of course.

The section for the student’s assessment and plan are placed on a separate sheet at the end of the exam form, after the attending doctor’s assessment and plan. This is to assure compliance with Medicare guidelines and the independence of the attending doctor’s conclusions from those of the student.

Mark O’donoghuem
Roger Wilson
Charles F. Mullen

by Charles F. Mullen

Development of a New Clinical Training Model

Development of a New Clinical Training Model (PDF)

Development of a New Clinical Training Model (PPT)

Background

Since the 1970’s, optometry has been in a state of metamorphosis with the introduction of pharmaceuticals and advanced clinical procedures. Optometric clinical education likewise has evolved in response to the expanded patient management and treatment responsibilities of optometric practice. However, the traditional clinical training model and terminology is not consistent with the current functional reality and presents obstacles to inclusion in and compliance with major federal programs.

The profession of optometry has benefited from inclusion in the federal program Medicare by being classified in medical terminology as physicians and are treated on a par with other physicians (MD, DO, DMD, DPM) regarding payment for patient services. Optometric education, however, does not conform to medical terminology nor the medical training model. Federal agencies administer health care and health education programs based on the medical model and terminology. While optometry is included in the Health Professions Student Loan programs, it is excluded from numerous special Federal Health Professions Education Programs sponsored by the Health Resources and Services Administration (HRSA) and from the Graduate Medical Education (GME) program, the educational component of Medicare. The Federal Government appropriates billions of dollars per year for the programs, but optometry is not eligible for these funds while all other health professions participate in these programs.

The premise behind why GME payments are made to financially support clinical training of physicians, dentists and podiatrists is that clinical training is inherently inefficient. All clinical training for optometry students, however, must take place in the four-year curriculum and not in post graduate residency programs since the graduate must be prepared to enter practice after graduation. The financial burden for the inherent inefficiencies in clinical training is placed upon the optometry student in the form of higher tuition. Inclusion of optometry in GME would provide additional revenue to optometric clinical facilities to partially offset the cost of these inefficiencies.

Medicare bases its regulations on the medical teaching model. Optometry’s traditional teaching model and terminology is not analogous to the medical model. However, functionally optometry’s model is consistent in several important aspects with the medical model. Current Medicare regulations regarding student supervision significantly impede optometry students from acquiring patient evaluation and management skills, since regulations do not permit third and fourth year optometry students to contribute to billable services. Medical interns, residents and fellows, however, can contribute to billable services and have ample opportunity to acquire patient evaluation and management skills without significantly affecting the efficient provision of health care.

Realignment of the traditional optometric clinical training model and terminology is necessary to facilitate inclusion in and compliance with major federal programs and to reflect the current functional reality.

Objectives of a New Clinical Training Model

The main objective of a new model and terminology would be to position optometry to be consistent with current Federal law and regulations pertaining to eligibility for GME, National Health Service Corps (NHSC), and Medicare billable services regulations and facilitate inclusion in and compliance with these programs. Participation in GME and NHSC would provide significant Federal resources currently not available to optometry. Realignment of the clinical training model would also ensure that third and fourth year optometric trainees receive meaningful and cost-effective training in patient evaluation and management (E/M) by placing optometric trainees in full compliance with Medicare billable service regulations without the need for the attending to repeat all clinical procedures.

Other objectives include increasing participation in Medicare, increasing the number of community-based training sites, and controlling educational debt. Inclusion in GME would result in significant funds paid to optometric clinical facilities for participation in the Medicare program. Given the financial benefit, GME participation would encourage an increase in Medicare services provided. The NHSC would provide significant resource and loan repayment for optometric residents and graduates practicing in federally-qualified health centers. Inclusion in the NHSC would encourage schools and colleges of optometry to increase the number of affiliated community-based training sites. Community-based training has proven to be highly cost-effective. The NHSC provides an opportunity for student loan repayment up to $50,000, thus providing a means to help control student debt.

Functional Reality of Current Optometric Training Model

Optometry residents are not truly residents, but function as medical attending or fellows according to the Department of Health and Human Services (HHS). The fourth year of optometric education has evolved into an intense clinical experience in response to the expansion of patient management and treatment responsibilities of optometric practice and is analogous to medical residency training. Fourth year students are expected to evaluate and manage patients and function as medical residents. Third year optometry clinical training has also increased in intensity in response to the expanded scope of optometric practice. This is the transitional year from classroom and laboratory activity to patient care. Supervised third year optometry students function as medical interns. First and second year optometry students have limited clinical training and function, for the most part, in a manner similar to medical students. (Table 1.)

A Before and After Look at Optometric Clinical Training Models

Actions Required to Realign the Optometric Clinical Training Model

The following actions are required to place the traditional optometric clinical training model in conformance with functional reality and medical terminology. Current third year optometry students would be redesignated as interns and current fourth year students would be redesignated as first year residents (Post-Graduate 1 or PG-1). Current optometric residents would be reclassified as PG-2, PG-3 or Fellows. First and second year students would remain classified as students. Since fellows, residents and interns can contribute to Medicare billable services, optometric trainees in this new configuration could receive meaningful and cost-effective training in patient evaluation and management (E/M), while in full compliance with Medicare billable services regulations.

In order to qualify for GME, the Social Security Act needs to be amended to require the Secretary of HHS to make Medicare, Graduate Medical Education (GME) payments to optometric affiliated facilities for certain costs associated with the clinical training of optometric interns and residents (PG-1 – PG-3), including resident stipends. Existing law/regulations need to be amended to direct HRSA to include optometry in the National Health Service Corps (NHSC). Inclusion in the NHSC would provide for resident stipends and educational loan repayment for up to $50,000 as well as other potential resources.

Conclusion and Recommendation

The traditional optometric training model and terminology are not consistent with the functional reality, with medical terminology and federally-supported programs and present obstacles to inclusion in and compliance with major Federal programs. There is a need to comply with Medicare regulations regarding student billable services and significant benefits of inclusion in GME and the NHSC. Formation of a broad-based task force is recommended to thoroughly review the issue regarding clinical training models, terminology and related considerations. Also, the task force would contribute to the political strategy to include optometry in GME and NHSC.

Journal of Optometric Education
Volume 32, Number 1, Fall 2006
Charles F. Mullen, O.D., F.A.A.O.

by Charles F. Mullen